1194108688 NPI number — NEIGHBORHOOD LTC PHARMACY INC

Table of content: (NPI 1194108688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194108688 NPI number — NEIGHBORHOOD LTC PHARMACY INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEIGHBORHOOD LTC PHARMACY INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NEIGHBORHOOD LTC PHARMACY
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194108688
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/02/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1265 S COTNER BLVD STE 30
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN
Provider Business Mailing Address State Name:
NE
Provider Business Mailing Address Postal Code:
68510-4924
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
402-488-1184
Provider Business Mailing Address Fax Number:
402-488-1187

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5115 S 111TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OMAHA
Provider Business Practice Location Address State Name:
NE
Provider Business Practice Location Address Postal Code:
68137-2341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
402-983-9600
Provider Business Practice Location Address Fax Number:
402-983-9601
Provider Enumeration Date:
07/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
LOUDERBACK
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
402-802-4871

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  3063 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336L0003X , with the licence number: 4587 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 10026514000 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2152887 . This is a "PK" identifier . This identifiers is of the category "OTHER".




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